The History in Headache

1. The History in Headache Steve Elliot GPwSI Headache

4. History taking in episodic headache • History taking in chronic headache • 3minute neurological examination • Who to refer for scanning • (Management of headache)

5. “Listen to the patient. He is telling you the diagnosis” Sir William Osler (1849-1919)

6. “The headache history has to be taken, not received” Professor Peter Goadsby

8. Why does it matter? • Headache is not a diagnosis • Clear diagnostic criteria • Diagnosis before treatment • Disease specific treatments

9. Guatama Buddha 563-483 BCHow to relieve suffering

10. 8 questions - the way to end suffering in headache • Location? • Character? • Severity? • Aggravation by movement? • Nausea/vomiting? • Photophobia? • Phonophobia? • Duration?

11. IHS tension headache 2 of • Bilateral • Pressing./tightening/non pulsating quality • Mild to moderate intensity • Not aggravated by movement No more than 1 of • Nausea/vomiting • Phonphobia or photophobia Duration 30minutes to 7days

12. IHS migraine Need 2 out of: • Unilateral • Moderate-severe • Throbbing • Worse with movement Need 1 of • Nausea and/or vomiting • Photophobia and phonophobia Duration 4-72 hours

13. SIGN guidelines “Neuroimaging is not indicated in patients with a clear history of migraine,without red features for potential secondary headache,and a normal neurological examination”

14. Cluster headache • Side locked unilateral • Peircing /drilling/grinding • Very severe • Not worse with movement • Possibly nausea/vomiting • Possibly unilateral photophobia • Possible phonophobia • 15-180 minutes duration • Autonomic symptoms • Restless

15. Landmark study • 1203 patients • GP diagnosis of primary headache • Headache diary for 3months • Diaries analysed by blinded assessors Findings: • 94% migraine or probable migraine • 82% “tension type headache” had migraine

17. “Brain attack” • Trigger – Dorsal pons • Prodrome - Hypothalmus • Aura – Cerebral cortex • Peripheral sensitisation – Cranial vasculature • Central sensitisation – Thalamus • Nausea/vomiting- Area Postrema • Autonomic symptoms – Parasympathetic system • Neck pain – Sensitisation of C2/C3

18. Why me? • Blame your parents • Chemical imbalance • Your brain is different • Symptoms between attacks

19. Chronic headache • 2-3% of population have headache on more days than don’t • Half of above have medication overuse • 2%/year migraine transforms to chronic • Most preceded by episodic headache • Co-mordidities anxiety,depression,obesity • Difficult to manage

20. Causes chronic daily headache Primary headaches • Chronic tension type headache • Chronic migraine • Chronic cluster headache • Medication overuse headache • New daily persistent headache • Hemicrania continua

21. History in chronic headache • Pattern Low grade all time? Low grade with exacerbations? Short lasting frequent? • Stable or progressive? • 8 questions • Medication including OTC? • Caffeine consumption? • Exclude red flags

22. What not to miss • Idiopathic intracranial hypertension • Low pressure headache • Giant cell arteritis • Other secondary headache REMEMBER • High pressure headache WORSE on lying flat • Low pressure headache BETTER lying flat

23. How to perform a headache examination

24. 3minute headache examination • Romberg • Palm drift • Pupil responses • Fields • Play piano • Finger-nose • Tandem gait • Facial movements • Eye movements • Fundoscopy • Protrude tongue • Limb and plantar reflexes • Corneal reflexes

25. Don’t forget • BP • Palpate temporal arteries >50 • ESR/CRP >50 • DOCUMENT WHAT YOU DO

26. Neuroimaging guidelines- a brief summary

27. What do we know? • Incidence of brain tumour in general population is 0.06-0.01% per year • 72% occur over age 50 • In primary care risk of brain tumour with headache presentation is 0.09% • If GP makes diagnosis of primary headache risk is 0.045% • If GP cannot make diagnosis then risk is 0.15%

28. NICE, TWW and headache • Headaches in whom a brain tumour is suspected • Headache of recent onset accompanied by features suggestive of raised intracranial pressure eg Vomiting Drowsiness Posture related headache Pulse synchronous tinnitus Or by other focal or non-focal neurological symptoms eg blackout,change in memory or personality • New, qualitatively different,unexplained headache that becomes progressively severe

29. But... • Tension type headache 58-77% of brain tumours • Migraine like in 7-9% but atypical features • Intermittent headache in 62-88% • 8% headache as only symptom • 74% brain tumours present within 3months • 90% within 6 months • Brain tumour headache may be similar to previous headache but more frequent/severe and associated with new symptoms

30. Red flags-SIGN guidelines • New onset or change in patient over 50 • New onset headache with history of cancer • Abnormal neurological examination • Headache that changes with posture • Headache that wakes (most common migraine) • Headache precipitated by physical exertion/Valsalva • Non focal neurological symptoms eg cognitive disturbance) • Patients with risk factors for CVST • Jaw claudication or visual disturbance • Neck stiffness • Fever • Change in headache frequency,characteristics or associated symptoms • Thunderclap headache • Headache that changes with posture • New onset in patient with HIV

31. Red flags-BASH guidelines Risk of underlying tumour >1% Warrant urgent investigation • Papilloedema • Significant alterations in consciousness,memory,confusion or co-ordination • New epileptic seizure • New onset cluster headache (non urgent) • History of cancer elsewhere particularly breast or lung

32. Orange flags -BASH Probability of an underlying tumour 0.1-1% Careful monitoring and low threshold for investigation • New headache where diagnosis not clear after 8weeks • Abnormal neurological exam or other neurological symptoms • Headache aggravated by exertion or Valsalva’s manoeuvre • Headaches associated with vomiting • Headaches which have been present for some time but have changed significantly, particularly rapid increase in frequency • New headache in patient over 50 • Headache which wakes from sleep • Confusion

33. Yellow flags- BASH Probability of underlying tumour between 0.01 and 0.1% Need for follow up not excluded • Diagnosis of migraine or tension type headache • Weakness or motor loss • Memory loss • Personality change

34. Acute medication in migraine • Paracetamol • Aspirin 900mg • Naproxen 500mg • Domperidone if nausea • Consider suppositories • Almotriptan 12.5mg • Other triptan if Almotriptan ineffective • Zolmitriptan nasal spray • Sumatriptan injection

35. Prophylaxis • Propranolol 80-240mg • Amitriptyline 10-100mg • Pizotifen if young • Topiramate or Epilim • Take 6-8 weeks to kick in • See regularly

36. Don'ts in migraine treatment • Over the counter • Opioids • Caffeine • Migraleave • Analgesia more than 2-3 days per week

37. Sir William Osler again “One of the first duties of the physicians to educate the masses not to take medicines”

38. Medication overuse headache • Headache >15 day per month • Intake of following for 3months Simple analgesia >15 days per month Or Opioids/triptans/combination analgesia >10 days per month • Headache resolves or returns to previous pattern within 2months of discontinuation of analgesia

39. What do you do when you get a headache? • Stay still =Migraine • Pace up and down = Cluster • Take tablet = Medication overuse

40. Management of chronic headache • Exclude red flags • Establish phenotype • Lifestyle measures • Avoid caffeine • Stop analgesia • (Occasional Naproxen) • Start prophylaxis according to phenotype • Regular follow up

41. “ The very first step towards success in any occupation is to become interested in it” Sir William Osler (1849-1919) Canadian Physician